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Title

Abstract

This case study follows the rehabilitation of a 62yr old male, transtibial amputee with PVD and Type 2 Diabetes. In Northern Ireland the number of adults diagnosed with diabetes has increased by 33% in 5 years. These issues are being addressed by a new strategy published by DHSSPS with an action and implementation plan from 2014. My aim was to evaluate the patient's assessment, treatment and outcome measurements with reference to the WHO ICF framework and current guidelines in the literature. This case supported current practice but also highlighted areas for improvement.

Key Words

Amputee, Diabetes, PVD, Northern Ireland, Recommendations, BACPAR

Client Characteristics

62-year-old man with a 8 week post-op following right transtibial amputation secondary to PVD and Type 2 Diabetes

Past medical History:

PVD Type 2 DM but on Insulin - poor glycaemic control CKD- not on dialysis

Diabetic foot ulcers

Diabetic neuropathy bilateral feet - no retinopathy

Gout

no MI/COPD/CVA/OA/RA/#/other surgery

History of Present Condition:

Several months h/o non healing diabetic foot ulcers.

Seen regularly by podiatrist.

Referred to hospital for vascular opinion.

Failed attempt at revascularisation of foot.

Decision to do TT amputation.

Post op c/o phantom limb pain.

Commenced on Pregabalin.

Still has ulcer on right great toe. being dressed regularly by podiatrist.

Discharged 7 days postop from Acute hospital to home.

Social History:

Married with 2 sons aged 25 and 22 - not living at home.

Lives in 2 storey house. 2 steps to front door.

Ramped access back door.

Bedroom and bathroom with shower upstairs.

Currently sleeping in lounge, using basin to wash and borrowed commode downstairs.

Wife is main carer - no health issues at present.

Able to transfer independently bed to wheelchair to commode.

Wife assists lower half dressing.

Retired lorry driver.

No plans to return to work.

Smokes 20/day. 6 units of alcohol a week.

No assessment by OT at present.

Using W/C on loan from the Red Cross.

Hobbies- watching local football team.

Watching sport on TV

Driving- hopes to return to driving. Has not yet informed DVLA

Examination Findings

All UL full functional

ROM and Muscle power

Movement

R ROM

R Muscle Power

L ROM

L Muscle Power

Hip Flex

115

4

120

5

Hip Ext

0

4

5

4

Hip Abd

30

4

35

5

Hip Add

15

5

20

5

Hip Int Rot

20

4

25

5

Hip Ext Rot

15

5

20

5

Knee Flex

120

5

120

5

Knee Ext

-10

4

full

5

Ankle D Flex

5

5

0

5

Ankle P Flex

50

5

55

5

Power Dexterity: good pincher grip but some reduction in fine dexterity

Balance: Pt tends to sit slouched but able to correct this when asked. Able to achieve passive and active sitting balance.

Transfers: Independent transfers W/C to plinth using banana board without prosthesis. Sit to stand to zimmer frame with supervision.

Standing : Able to stand for several minutes using zimmer frame maintaining balance and no shortness of breath.

Discussion

Evidence to support current practice and change of practice using ICF Framework.

PATHOLOGY Pt has PVD, Diabetes, foot ulcers, poor glycaemic control and foot care. Diagnosed diabetes has risen in NI by 33% in 5 yrs. 1 in14 has had a foot ulcer. 1in10 foot ulcers result in 2 amputations/week here. Foot ulcers result from diabetic neuropathy and PVD.[4] After 1-5 years, 26-53% of dysvascular amputees in the UK require a 2nd amputation. BACPAR guidance recommends that prosthetic stability and gait should prevent abnormal loading of the contralateral limb. [5][6]

BODY FUNCTION AND STRUCTURE : No referral made for W/C, stump board, community OT. No EWA used and minimal advice on ex. Pt did not wear juzo. This resulted in oedematous stump,FFD at knee,weak hip & core muscles. Guidelines recommend use of a stump board, EWA and juzo shrinker.[7][8][9]Pt had fallen when transferring. BACPAR guidance recommends balance exs to reduce falls risk. [10]Rehab was based on BACPAR guidelines,Engstrom,the Prosthetic Gait Analysis for Physiotherapists & Bob Gailey[1][2][3][4]

ACTIVITIES: Pt will always be W/C user and may become bilateral[5]. BACPAR guidance on the contralateral foot recommends education re risk factors and foot care.[5]

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